Prevention & Early Intervention Series, Focussed Policy Assessment No.8

Prevention and Early Interventions Supporting

Health and Well-Being in Older Age

Fiachra Kennedy

Prevention & Early Intervention Unit

October 2019

This paper has been prepared by staff in the Department of

Public Expenditure & Reform. The views presented in this paper

are those of the author alone and do not represent the official

views of the Department of Public Expenditure and Reform or the

Minister for Public Expenditure and Reform.

IGEES Irish Government Economic and Evaluation Service

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Under A Programme for a Partnership Government, the Department of Public Expenditure & Reform has established a Prevention and Early Intervention Unit (PEIU). The focus of the PEIU’s work is on prevention and early interventions that can improve the life outcomes of children as well as the quality of life of older people dealing within long term conditions such as chronic illness; which the PEIU is locating within the context of population health. These types of interventions have a strong common-sense appeal; most people are familiar with the idiom that “prevention is better than cure”. However, effective prevention and early interventions rely on both knowing what to do (scientific understanding of cause and effect) and being in a position to act (the capacity of the government to intervene). The PEIU is undertaking a series of Focussed Policy Assessments on key prevention and early interventions supported by public resources. The approach is to describe each intervention by following a common structure:

Rationale for the intervention;

Public resources provided to support the delivery of the intervention;

Outputs and services provided; and

Achievements of the intervention relative to its stated goal. As a whole, this series of descriptive reports will provide the evidential base for a thematic consideration of prevention and early interventions in Ireland.

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Contents Introduction 3

Understanding Health and Well-Being in Older Age 6

Health and Well-Being 6

Quality of Life 8

Health Status 8

Behavioural Factors 10

Latent Factors 12

Age Friendly Environment 14

Demographics 15

Lived Old Age in Ireland - Health and Well-Being 17

Quality of Life 17

Health Status 19

Behavioural Factors 24

Latent Factors 29

Age Friendly Environment 34

Prevention and Early Interventions Supporting Health and Well-Being in Older Age

35

Health Risk Behaviours 35

Frailty and Falls 37

End-of-Life Experiences 38

Social Interaction 38

“Warmth and Wellbeing” Pilot Project 39

Age Friendly Environments 40

Bibliography 44

Table 1 – Key Factors Associated with Health and Well-Being in Older Age 7

Appendix A – National Goals and Objectives of the National Positive Ageing Strategy

42

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Introduction1 One of the many ways in which Irish society is changing is people are living longer lives.2 While this change ought to be seen in a positive light, as a reflection of how life in Ireland has improved for the better, there is a tendency to emphasise the challenges presented by an ageing population. As has been experienced in other countries, Ireland’s ageing population is likely to lead to increased demands for pension provision and health and social care services with implications for public expenditure policy both in terms of capital investment and the provision of capacity within the various services.3 In planning for the future, it is important to acknowledge and plan for these challenges. However, these plans should be about more than just preparing to meet the needs of an ageing society. Over the last four decades or so, there has been an international movement toward seeing later years as a time of new beginnings and of new possibilities.4 Gibney et al. (2018: 10) have noted that the World Health Organization has:

“identified population ageing as one of humanity’s greatest triumphs and greatest challenges… countries can afford to get old if governments, international organisations and civil society enact ‘active ageing’ policies and programmes that enhance the health, participation and security of older citizens.”

1 The author is grateful to colleagues in Department of Health for their comments and insights. The author is also grateful to Dr. Fiona Keogh of the Centre for Economic and Social Research in Dementia (NUI Galway) and Catherine McGuigan and Dr. Emer Coveney of Age Friendly Ireland for their comments and insights. 2 Over the last century, life expectancy at birth has increased from around 54 years for both males and females in 1911 to about 69 years for males and 73 years for females in 1971 to about 78 years for males and 83 years for females in 2011. (Central Statistics Office, Key Table VSA30. Accessed: 6 June 2019) The age profile of the Irish population is also changing. The most recent Census indicates that in 2016 the population of Ireland aged 65 years and older was some 637,570 people (13% of the total population). In 1971, the number of people in this age group was 329,820 (11%) and in 1926 it was 271,680 (9%). (Central Statistics Office, Key Table E2002. Accessed: 6 June 2019.) While it is evident that the increase in the number of older people is accelerating, this increasing rate of change is even more evident amongst those aged 85 years and older; increased by 41% between 1926 (14,860) and 1971 (20,930) and by 223% between 1971 and 2016 (67,555). The population aged 65 years and older increased by 21% in the 45 years between 1926 and 1971 and by 93% in the 45 years between 1971 and 2016. It is projected that the Irish population will continue to increase over the next few decades and that the number of people aged 65 years and older will be in the region of 1 million by 2031 and 1.4 million by 2046 (i.e. people born in 1981). Similarly, the population aged 85 years and older is projected to increase to around 133,000 by 2031 and 256,000 by 2046 (i.e. people born in 1961). 3 Wren et al. (2017) have provided an extensive examination of projections of healthcare demand to 2030 that indicate increased demands for: (a) public hospital services including inpatient bed days, inpatient and day-patient cases, Emergency Department attendances Outpatient Department attendances; (b) private hospital services including inpatient bed days and inpatient and day-patient cases; (c) GP and practice nurse visits; (d) community pharmaceuticals and pharmacy services; (e) long-term and intermediate care resident places and bed days; (f) home care packages and for home help hours; (g) public health nursing and community therapy services including public health nursing visits, public physiotherapy visits, public occupational therapy visits and public speech and language therapy visits. 4 For instance, the UN First World Assembly on Ageing (1982); UN Principles for Older Persons (1991); International Year of Older Persons (1999); UN Second World Assembly on Ageing, the Madrid International Plan of Action on Ageing (2002); Europe 2020 - Innovation Union (2010); the European Innovation Partnership on Active and Healthy Ageing (2011); European Year for Active Ageing and Solidarity between Generations (2012).

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In this context, it is also important to work towards ensuring the additional years of life experienced by increasing numbers of people living in Ireland are lived in health. The National Positive Ageing Strategy vision is of an Ireland that:

…celebrates and prepares properly for individual and population ageing. It will enable and support all ages and older people to enjoy physical and mental health and wellbeing to their full potential. It will promote and respect older people’s engagement in economic, social, cultural, community and family life, and foster better solidarity between generations. It will be a society in which the equality, independence, participation, care, self-fulfilment and dignity of older people are pursued at all times.5

A focus on supporting health and well-being in older age is not simply about the absence of disease and infirmity. Instead, it is about a person’s complete physical, mental and social well-being. When a person has positive physical, social and mental well-being their basic needs are met, they have a sense of purpose, they feel they can achieve goals that are important to them, they are able to participate in society and they find value in the lives that they live.6 From a policy perspective, this approach points to the need for a whole of government approach. The World Health Organization (2002) has set out a roadmap for designing multi-sector active ageing policies. This policy framework seeks to encourage policy makers to recognise and address factors that affect how people and populations age, to adopt a life-course perspective and to promote intergenerational solidarity in developing policies to respond to population ageing. The World Health Organization has defined active ageing as a process of optimising opportunities for participation, health and security. In Ireland, these three elements of active ageing are evident in the national goals set out in the whole of government National Positive Ageing Strategy7 (See Appendix A.):

The first goal is concerned with removing barriers and providing opportunities for people to be involved in all aspects of life. In particular, this goal references employment and education, active citizenship and volunteering, engagement and participation in their local communities and enabling people to “get out and about”.

The second goal is concerned with supporting people’s physical and mental health and well-being. In particular, it focuses on preventing and reducing disability and chronic illness and promoting the development and delivery of high quality care services and supports.

The third goal is concerned with enabling people to age with confidence, security and dignity in their own homes and communities. To this end it focuses on people’s income and standard of living, the quality of their homes, the accessibility of public spaces, transport and buildings and their feelings of safety and security both within and outside their homes and families.

The implementation of the National Positive Ageing Strategy requires a whole of government response and is framed within the implementation of Healthy Ireland (the whole of government national framework for action to improve health and well-being of the population):

5 Department of Health, 2013a: 18. 6 Department of Health: 2013b: 9; Diener, 2006: 156; Dolan, 2014; Ryan and Deci, 2001; Ryff and Singer, 2008; Stiglitz, Sen and Fitoussi, 2009. 7 Department of Health, 2013a: 20-21.

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…everyone can enjoy physical and mental health and wellbeing to their full potential, where wellbeing is valued and supported and at every level of society and is everyone’s responsibility.8

Within its vision, Healthy Ireland emphasises:

The need for public policy to focus on health and wellbeing over the life-course and across the broader determinants of health; and

Personal and collective responsibility for protecting health and preventing disease. Amongst its high-level goals, Healthy Ireland intends to:

Increase the proportion of people who are healthy at all stages of life; and

Reduce health inequalities. Gibney et al. (2018: 11) have noted that the implementation of the National Positive Ageing Strategy is an essential part of creating the vision set out in Healthy Ireland of a society in which “every individual and sector of society can play their part in achieving a healthy Ireland”. There is a tendency to think of prevention and early interventions in terms of policy for children and young people. However, prevention and early intervention is an important element of Ireland’s policy focus on ageing. The Sláintecare Report (2017: 71) identified health promotion and the prevention of ill-health as a key element of it vision for integrated care in Ireland. In terms of the population as a whole, the policy focus of Healthy Ireland is to increase the proportion of people who are healthy at all stages of life. In terms of older people, the National Positive Ageing Strategy have been set out above (and in Appendix A). While the HSE’s National Clinical Programme for Older People seeks to improve the management of acutely ill frail older adults in the acute hospitals, it is also seeking to reduce the number of falls by older people and increase their independence in the home. Interventions that seek to support health and well-being in older age need to be concerned not only with people’s physical and mental health but also with their ability to play an active part in society without discrimination and to enjoy an independent and good quality of life.9 This paper seeks to illustrate how a prevention and early intervention approach to designing and implementing policies, might be useful in supporting positive health and well-being outcomes for older people.10 The paper initially sets out a broad range of interrelated factors that are important to consider when trying to understand how to support better health and well-being in older age. These factors influence health and well-being over the course of a lifetime

8 Department of Health, 2013b: 6. 9 The World Health Organization (WHO) has been central to policy initiatives that have sought to develop societies in ways that support older people in continuing to lead active and healthy lives. In particular, the WHO (2002, 2015) has set out a framework that provides a roadmap for involving multiple agencies in designing multi-sectoral active ageing policies. (See also: Department of Health. 2013a: 63-64; Baltes and Baltes, 1990.) 10 In drafting this report, the author only considered publically available information and did not have access to any considerations that might be underway as to how the programmes considered could be developed. As noted this report is part of a series of reports that taken together will inform a thematic consideration of prevention and early interventions in Ireland. As such, within this overall approach the individual reports are not evaluations of the programmes considered and do not seek to arrive at any conclusions or make any recommendations.

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so it is important to take account of a person’s current circumstances and behaviours as well as the accumulation of positive and negative effects of how their life has been lived. The paper then focuses on trying to describe how old age is lived in Ireland. Research evidence published by The Irish Longitudinal Study on Ageing, the Healthy Ireland Survey and the Healthy and Positive Ageing Initiative Survey are used to describe health and well-being amongst older people living in Ireland and to set out how the various factors are related to each other. The final section of this paper outlines a number of examples of interventions that seek to address one or more of the factors associated with health and well-being in older age. As the various factors are amenable to policy interventions, there are opportunities for policy interventions that can promote better health and well-being amongst older people.

Understanding Health and Well-being in Older Age The purpose of this section is to set out key factors that support an understanding of health and well-being in older age. In older age, a person’s health and well-being is influenced by complex interactions of a range of factors over the course of their life. A life course approach to understanding health and well-being in older age involves taking account of a person’s current circumstances and behaviours as well as the accumulation of positive and negative effects of social, economic and environmental conditions throughout their life (i.e. the circumstances in which people are born, grow up, live, work and age).11

Health and Well-Being A central concern with realising the benefits of increased life expectancy is how life is lived in older age. If the benefits of the changes in life expectancy are to be fully realised then the focus has to be on more than the delayed onset of morbidity and infirmity. From this perspective, policy is concerned with a person’s complete physical, mental and social well-being.12

11 Bell, 2017: 5-10; World Health Organization, 2002; Department of Health, 2013a, 2013b and 2015c. 12 For instance, the WHO Regional Committee for Europe has set out a Strategy and Action Plan for Healthy Ageing in Europe, 2012–2020. Within this it has set out four strategic priority areas for action that help people to stay active as long as possible (including in the labour market) and actions to protect the health and well-being of people with (multiple) chronic conditions or at risk of frailty: healthy ageing over the life-course; supportive environments; health and long-term care systems fit for ageing populations; and strengthening the evidence base and research. The Strategy and Action Plan also suggests five priority interventions: promoting physical activity, falls prevention; vaccination of older people and infectious disease prevention in health care settings; public support to informal care-giving, with a focus on home care; and geriatric and gerontological capacity-building among the health and social care workforce. Finally, it sets out additional supporting interventions that link healthy ageing to its wider social context: prevention of social isolation and social exclusion; prevention of elder maltreatment; and quality of care strategies for older people including dementia care and palliative care for long-term care patients.

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Table 1 provides a summary of the some of the key factors that support an understanding of health and well-being in older age. These factors include more than a traditional focus on the physical and mental health of older people13:

A healthy ageing approach that focuses on optimising opportunities for physical, social and mental health in order to enable older people to take an active part in society without discrimination and to enjoy an independent and good quality of life;

Ideas around active ageing that emphasise people’s continued participation in all aspects of their communities (e.g. social, economic, cultural, spiritual and civic affairs) and not just the ability to be physically active or to participate in the labour force;14

A positive ageing approach that moves beyond a concern with a person’s physical, emotional and mental well-being to include social attitudes and perceptions of ageing that can influence the well-being of older people, whether through direct discrimination or through negative attitudes and images; and

A successful ageing approach that accounts for the dynamic or life-cycle element of ageing as it is concerned with the ability of people to adapt to the transitions experienced by the ageing person; preventing or reducing the negative impacts on their quality of life.15

Table 1 – Key Factors Associated with Health and Well-being in Older Age16

Latent Factors Behavioural Factors Health Status Quality of Life Adversity Personal Safety Resilience Beliefs and Attitudes

Health Risk Physical Activity Social Integration

Physical Health Disability Frailty Falls Cognitive Function and Dementia

Control Autonomy Self-Realisation Pleasure

Age Friendly Environments

Demographics

13 Department of Health. 2013a: 63-64; Department of Health, 2015a: 2-3; Baltes and Baltes, 1990. 14 Bass, Caro and Chen, 1993; OECD, 1998. 15 Depp and Jeste, 2006; Montross et al., 2006. 16 What is set out here is not exhaustive but is intended to provide a broad overview of key factors that are associated with Health and Well-being. In part, the selection of domains and factors included here has been influenced by the empirical work published by TILDA as well as with concern to focus on elements that are amenable to policy actions in support of better outcomes for older people.

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Quality of Life Quality of life is an important measure of well-being. The World Health Organization has defined quality of life in terms of:

the individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by a person's physical health, psychological state, level of independence and their relationships to salient features of their environment.17

Quality of life is a multi-dimensional concept encompassing not only a person’s physical health but also their psychological wellbeing, social functioning and participation in the world around them. This broader focus (beyond physical health) is important as it is not uncommon for older people to rate their quality of life as good even when they have a serious illness or disability.18 Quality of life focuses on a person’s ability to actively participate in the place where they live, live their life in a way that allows them to fulfil their potential and derive happiness or enjoyment and be free from the unwanted interference of others.19

Health Status

Physical Health As people and populations age, there are increases in both the prevalence and incidence of poor health as well as demand for health services. People’s quality of life can be undermined by reduced physical health and disability.20 Cardiovascular conditions continue to be a key cause of early mortalities in Ireland despite decreases in the age-standardised mortality rate.21 Cardiovascular conditions are also associated with secondary complications. For instance, people with diabetes are more at risk than their counterparts of cognitive decline and depression as well as Alzheimer’s Disease.22 Non-cardiovascular conditions can also contribute to a reduction in people’s quality of life.23 Diseases of this type can result in reduced physical activity and increased risk of disability that can have further negative consequences for people’s health and well-being. For instance, osteoporosis is associated with fractures while cataracts are one of the most common causes of vision loss in people over 40 years of age.24

17 World Health Organization Quality of Life Group,1997: 1. 18 McGarrigle and Ward, 2018; McGee, Morgan, Hickey, Burke and Savva, 2011; Bowling and Dieppe, 2005. 19 Sen (1999) emphasises whether or not a person has the necessary capabilities or opportunities to lead the kind of life they value (e.g. are they well nourished, mobile, take part in community life). 20 George, 2010; Stegenga et al, 2012. 21 McNicholas and Laird, 2018. Cardiovascular conditions include hypertension, diabetes, heart attack, angina, stroke, transient ischaemic attach (TIA) and heart failure. 22 Downs and Spezia Faulkner, 2015. 23 For example, cataracts, osteoporosis, arthritis and lung disease. 24 McNicholas and Laird, 2018.

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Disability The risk of disability increases as people age. There are many types of disability but a distinction is often drawn between those that impact on “activities of daily living” (e.g. washing, eating and toileting which are essential to daily life) and “instrumental activities of daily living” (e.g. preparing meals, managing money and household chores which are important in maintaining independence). In addition to the impact of disability on “daily living”, it can also hinder a person’s ability to access their community. When this happens it can reduce their quality of life and contribute to depression, social isolation and loneliness.25 That said, the negative impact of disability on life satisfaction may reduce over time26 as people’s resilience helps shape how they adapt to disability.27

Frailty

In terms of addressing the health needs of an ageing population, frailty is becoming a key concept in terms of healthcare service planning, development and delivery.28 Frailty is a distinctive health state related to the ageing process during which multiple body systems gradually losing their in-built reserves. In frail people there is an increased risk that a minor health related event (e.g. an infection, dehydration or adverse effects related to a new medication) could result in a deterioration of their health.29 Those living with frailty tend to have:

Difficulty walking a short distance;

Difficulty climbing stairs;

Exhaustion/having energy to spare;

Extent of physical activity; and

Co-morbidity of two or more of hypertension, lung disease, stroke, diabetes, angina and heart problems.30

However, frailty is not an inevitable part of the ageing process. While frailty is a common condition in older adults, it is a dynamic process that changes over time. An older person can transition between the different states of frailty:

Robust – a person’s health problems are well managed;

Pre-frailty – a person is coping with their health problems but are at increased risk of adverse outcomes; and

25 McGarrigle and Ward, 2018; Barry, Soulos, Murphy et al. 2013; Sexton, King-Kallimanis, Layte and Hickey, 2015; Burholt and Scharf, 2014. 26 Oswald and Powdthavee, 2008. 27 Hayslip and Smith, 2012. 28 Health Service Executive, 2017. 29 O’Halloran and O’Shea, 2018; Roe, O’Halloran, Normand and Murphy, 2016; Clegg, Young, Iliffe et al., 2013. 30 Scarlett, King-Kallimanis, Young, Kenny and O’Connell, 2014.

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Frailty – a person has complex health problems and functional limitations such that they are at high risk of adverse health outcomes (e.g. falls, disability, hospitalisation, nursing home admission and death).31

Falls Falls are the leading cause of injury, disability and admission to nursing homes for people aged 65 years and older. A single fall significantly increases the risk of subsequent falls. In terms of injury, hip fracture is the most common disabling injury in older adults and can cause accidental death.32

Cognitive Function and Dementia Cognitive function and dementia have been identified as key risk factors for the onset of disability and reduced physical function in later life.33 In terms of cognitive function, as people age, they may encounter difficulties with one or more of verbal memory (words and other abstractions of language), prospective memory (perform an action in the future; important in terms of maintaining independence by performing day-to-day tasks) and executive function (such as the ability to plan, utilise mental flexibility and to suppress inappropriate or incorrect responses). At older ages, these changes may impact on their ability to perform everyday tasks, retain autonomy and live independently.34 Dementia is a progressive condition that impacts on memory, language, ability to communicate, mood and personality. (Alzheimer’s disease is the most common cause of dementia.)35 From a clinical perspective, dementia is likely to begin at midlife (40-65 years) though symptoms may not be observed for some years. The Lancet’s Livingston Commission adopted a life-course approach to its review of dementia and posited that there is a window of opportunity to intervene and address a range of potentially modifiable risk factors at different stages of life. In particular, they identified low educational level in childhood, hearing loss, hypertension, obesity, smoking, depression, physical inactivity, social isolation and diabetes.36

Behavioural Factors

Health Risk Behaviours Behavioural health refers to modifiable risk factors (e.g., smoking, alcohol consumption and diet) that can have a negative influence on health and contribute to chronic disease.37 The impact of these behaviours is not only associated with current behaviour but is also related to the cumulative effect of these behaviours over the course of a lifetime.

31 O’Halloran and O’Shea, 2018; Gill, Gahbauer, Allore and Han, 2006; Fried, Ferrucci, Darer et al. 2004; Clegg, A., J. Young, S. Iliffe S et al., 2013. 32 McNicholas and Laird, 2018; Donogue, 2014; American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention, 2001; O’Loughlin, Robitaille, Boivin and Suissa, 1993; Dyer, Crotty, Fairhall et al., 2016. 33 Spiers, N.A., R.J. Matthews, C. Jagger et al., 2005. 34 Feeney and Tobin, 2018. 35 Morgan, Gibney and Shannon, 2017. 36 Livingston, Sommerlad, Orgeta et al., 2017. 37 McNicholas and Laird, 2018.

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Physical Activity Physical activity is recommended as an essential component of a healthy lifestyle at all ages because even moderate levels of physical activity can help prevent disease, improve quality of life and promote physical and mental health (physical inactivity is one of the leading risk factors for mortality).38 In adults aged 65 years and older, the health benefits of physical activity include:

Increased cardiorespiratory and muscle fitness, lower body fat, more favourable metabolic profile and lower rates of cardiovascular disease (including high blood pressure, stroke, type 2 diabetes) and cancer (colon and breast);

Better cognitive function and functional health and a lower risk of falling;39 and

Increased well-being and improved mental health and quality of life through social engagement.40

People who engage in little or no physically activity are at greater risk of premature death as well as cardiovascular disease, hypertension, type 2 diabetes, obesity, osteoporosis, anxiety and depression.41

Social Integration Social integration refers to the extent to which an individual has meaningful personal ties to friends and family and social ties to their community. People who engage in their communities are more likely to have better physical and mental health and are less at risk of pre-mature mortality. Social engagement is protective against cognitive decline and dementia and can influence levels of physical activity, healthy eating, and other positive health behaviours.42 However, low levels of social engagement are held to have a similar impact on people’s health as established risk factors such as physical inactivity, obesity, smoking and high blood pressure.43 Feelings of loneliness encompass missing close personal relationships (emotional loneliness) and wider social interaction. Such feelings reflect a deficit between a desired quality and quantity of engagement with others and the day-to-day reality of their engagement with others.44 In older adults, loneliness has been associated with declines in physical, mental and cognitive health and increased risk of mortality.45 Volunteering is on important source of social engagement. There is evidence to suggest that older adults who volunteered for at least 100 hours a year have slower declines in self-rated

38 McNicholas and Laird, 2018. 39 World Health Organization, 2010. 40 Chodzko-Zajko, Proctor, Fiatarone Singh et al., 2009; Heesch, van Uffelen, Hill and Brown, 2010. 41 Donoghue, O’Connell and Kenny, 2016. 42 Allen and Daly, 2016: 3-4. 43 Holt-Lunstad, 2017; Donoghue, O’Connell and Kenny, 2016; House, Robbins and Metzner, 1982. 44 Victor, Scambler, Bowling and Bond, 2005. 45 Holt-Lunstad, 2017; Donoghue, O’Connell and Kenny, 2016; Hawkley and Cacioppo, 2010; Hawkley, Thisted and Cacioppo, 2009.

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health and physical functioning, slower increases in depression levels and lower mortality rates compared to those who volunteered for less than 100 hours a year.46

Latent Factors In addition to factors that can be observed such as a person’s behaviour or health status, well-being can also be influenced by a variety of factors that are less observable such as people’s experiences of adversity over the course of their lives, as well as by the attitudes that they and society hold regarding ageing.

Adversity People of all ages encounter adversity. In general terms, adversity can be defined as a lack of positive circumstances or opportunities, which may be brought about partially by physical, mental or social losses, or by experiencing deprivation or distress.47 The Adverse Childhood Experiences Study has demonstrated the longer term impact of adversity on health outcomes.48 Exposure to stressful experiences may predispose people to developing chronic diseases such as diabetes, cardiovascular disease, liver cancer, asthma, chronic obstructive pulmonary disease, autoimmune diseases, poor dental health, and depression.49 In part, this may be due to people trying to cope and manage their experiences of adversity by adopting behaviours such as smoking, alcohol or drug abuse, overeating or sexual behaviours because of their immediate pharmacological or psychological benefits. For instance, nicotine has psychoactive benefits such as anti-anxiety, anti-depressant, anger-suppressant and appetite-suppressant.50 Furthermore, the experience of stress over a prolonged period of time, toxic stress51, can have long-term health consequences especially in the absence of protective coping strategies and healthy interpersonal relationships.52

End-of-Life Experiences

One obvious source of stress is people’s experience around end-of-life. Issues around death and dying are seen as important to quality of life. For many, there are feelings of uncertainty and fear around death (e.g., not feeling in control of how you die and fear of being in pain before death). While most people would prefer to die in their own homes, the experience in high-income countries tends to be one in which up to half of deaths occur in an acute hospital setting.53

Adult Safeguarding (Elder Abuse)

In recent years, efforts to safeguard vulnerable or at risk adults from abuse, neglect and exploitation have been encompassed by the field of adult safeguarding. The abuse and

46 Donoghue, O’Connell and Kenny, 2016; Lum and Lightfoot, 2005. 47 Hildon, Smith, Netuveli and Blane, 2008. 48 Felitti, Anda and Nordenberg, 1998; Felitti, 2009; Runyan et al, 2002; Singh and Ghandour, 2012; Appleyard, Egeland, van Dulmen, and Sroufe, 2005. 49 Downs and Spezia Faulkner, 2015. 50 Felitti et al., 1998: 253-254; Felitti, 2009. 51 The strong, frequent and prolonged activation of the body’s stress response systems. 52 Shonkoff and Garner, 2012; Johnson, Riley, Granger and Riis, 2013; Shonkoff, Boyce and McEwen, 2009; Shonkoff, 2012. 53 Power, Quinn and Schmidt, 2005; May, McGarrigle and Normand, 2017; Gomes, Higginson, Calanzani et al., 2006; Bekelman, Halpern, Blankart et al., 2016; Teno, Gozalo, Bynum et al., 2013.

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mistreatment of older people is an issue that has become more salient in public discourse over the last few decades.54 The World Health Organisation (2002) has defined elder abuse as:

a single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person or violates their human and civil rights.

Older people who have experienced abuse are at risk of premature mortality, emotional distress such as increased experiences of fear and grief, anger and upset, isolation from family and friends, the loss of self-confidence and self-esteem, depression and thoughts of suicide or self-harm.55 While elder abuse and neglect are the potential outcomes of complex interactions between social, economic, health, social isolation, education and so on, older people who are most at risk of abuse are those with a physical impairment and dependent on others for assistance with activities of daily living as well as older people co-habiting with family and being socially isolated.

Self-Neglect

More recently, there has been a focus on the issue of self-neglect by older people. Self-neglect occurs when people refuse to provide themselves with adequate food, water, clothing, hygiene and safety precautions and can threaten a person’s health and safety. The factors associated with risk of self-neglect include clinically significant depressive symptoms, cognitive impairment, alcohol abuse, low self-rated health, higher levels of pain and frailty.56

Resilience Morgan et al. (2016) have noted that having to deal with adversity is not always detrimental to the person. The experience of having to cope with low levels of adversity can enable people to deal with difficulties, “resilience”:

The capability of individuals or systems (such as families, groups, and communities) to cope successfully in the face of significant adversity and risk.57

Resilience is not an inherent trait. Instead, it is perhaps best understood as an interaction between psychological processes and ecological influences - it is both nature and nurture.58 Resilience results from a mixture of both protective and risk factors and ranges on a continuum from “basic survival” to “flourishing resilience”.59 Protective factors work to buffer an individual from the likelihood of negative effects of a particular problem60 and include positive attachment, self-esteem, intelligence, emotion regulation, humour and independence.61 (Protective factors may be at the level of the individual, their family or the community within which they live.)

54 Naughton, Drennan, Treacy, Lafferty, Lyons, Phelan, Quin, O’Loughlin and Delaney, 2010. 55 Lachs, Williams O’Brien et al., 1998; Comijs, Pot, Bouter and Jonker, 1998; O’Keeffe, Hills, Doyle et al., 2007; Mowlam, Tennant, Dixon and McCreadie, 2007; Mears, 2003. 56 Dong, Simon and Evans, 2011; Abrams et al., 2002; Hansen et al, 2016; Lee et al, 2016. 57 Lyons, Mickelson, Sullivan and Coyne, 1998. 58 Masten, 2001; Harrop, Addis, Elliott and Williams, 2006. 59 Palmer, 1997. 60 Shonkoff and Garner, 2012. 61 Child Welfare Information Gateway, 2013: 3.

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Personal Safety It is important that people feel safe both in their own homes and when they are out-and-about.62 For older people, feeling safe at home and in their neighbourhoods is a key element of a good quality of life.63 Older adults who perceive their neighbourhoods as unsafe, particularly at night, tend to engage in less physical activity, regardless of socioeconomic status.64 Another concern about their personal safety that older adults may have is in relation to falling. Given the potential negative health consequences of falling, many older people, including those with no history of falls, are afraid of falling. There is evidence that fear of falling is associated with an increased likelihood of experiencing a fall within two years. This may be because the fear of falling results in a person avoiding activities they are capable of performing and, as a consequence, experiencing increased social isolation and reduced strength, fitness and mobility.65

Beliefs and Attitudes Ageing tends to be seen in negative terms with stereotypes portraying older adults as physically weak, forgetful and stubborn. However groundless these biases may be,66 these perceptions can contribute to social inequalities and have a negative impact on how older adults function. The pervasiveness of ageism in society may mean that as people age, they themselves possess and articulate negative expectations about their own ageing. How people think about old age, and the societal biases they encounter, can influence well-being and health.67 For instance, older people who have a positive view of ageing are more likely to engage in preventive health behaviour, have fewer functional limitations and live longer68 while negative perceptions of ageing are associated with poorer quality of life among community-dwelling older people.69

Age Friendly Environment There is an increasing interest in promoting age friendly environments. As people age they can encounter difficulties moving around the communities in which they live (e.g. poor quality footpaths, lack of places to rest, inadequate lighting, heavy traffic). This can have a negative impact on their ability to access services or to continue to participate in their local communities. However, it is possible, through planning and designing the towns and cities in which people live, to build environments that are safe and accessible to older people and support people to continue living in their own homes and communities.70 One of the National Policy Objectives under the National Planning Framework (2018: 86) is that:

62 De Donder, de Witte, Dury et al., 2012. 63 Gabriel and Bowling, 2004. 64 Bennett, McNeill, Wolin et al. 2007; Tucker-Seeley, Subramanian, Li and Sorensen, 2009. 65 Donogue, 2014; Rantakokko, Mänty, Iwarsson et al., 2009. 66 World Health Organization, 2007a; Pinquart, 2002. 67 McGee, Morgan, Hickey, Burke and Savva, 2011. 68 Levy and Myers, 2004; Levy, Slade and Kasl, 2002; Levy, Slade, Kunkel and Kasl, 2002. 69 Hickey, O’Hanlon and McGee, 2010. 70 Garin et al., 2014; Bentley et al., 2013; Romero-Ortuno, Cogan, Cunningham, & Kenny, 2009; Michael, Green, & Farquhar, 2011.

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Local planning, housing, transport / accessibility and leisure policies will be developed with a focus on meeting the needs and opportunities of an ageing population along with the inclusion of specific projections, supported by clear proposals in respect of ageing communities as part of the core strategy of city and county development plans.

Demographics Finally, well-being is also associated with a range of social, economic and environmental factors (i.e. the circumstances in which people are born, grow up, live, work and age). While these factors are not usually the direct causes of illness, in older age, a person’s health is associated with the cumulative impact of these circumstances:71

Before a person is born, a maternal diet that is less rich in nutrients can impact on how the foetus develops heightening their risk in later life to diseases such as coronary heart disease, stroke, diabetes and hypertension;72

Maternal depression and economic deprivation can diminish a child’s cognitive and emotional development resulting in their being less ready for school and reducing educational attainment;73

Socioeconomic disadvantage and social exclusion can mean that some groups in society are “hard to reach” which can hinder their ability to access services such as health, education and housing in ways that undermine health and well-being in later life;74

People who are involved in providing informal care for relatives and others are at risk themselves of poor health, especially stress and depression. While a caring role can provide a person with a sense of purpose, self-esteem and well-being, it should be acknowledged that the role, in particular the duration and intensity of it, can impact on the health and well-being of the carer;75

In later life, a person with a greater ‘cognitive reserve’ of skills, abilities and knowledge to draw on has a better chance than their counterpart of coping with the onset of mild cognitive impairment and dementia;76

Experience of unemployment or poor quality / sporadic work impacts on a person’s ability to prepare financially for later life which can impact on their standard of living in older age and their levels of social engagement and physical activity;77

71 Allen and Daly, 2016; Marmot Review Team, 2010; Department of Health, 2013a. 72 Jefferis, Power and Hertzman, 2002; Barker, 1998. 73 Kiernan and Huerta, 2008. 74 Ní Shuinear, 1994. 75 Schulz and Sherwood, 2008; Heisler et al, 2012; Winter, Bouldin and Andresen, 2010. 76 Scarmeas and Stern, 2003; Richards and Sacker, 2003; Stern, 2003. 77 Allen, and Daly, 2016; Allen, Daly and Institute of Health Equity, 2016; Allen, 2008; Institute of Health Equity, 2004; Roberts and Bell, 2015.

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Unemployment can impact on people’s physical and mental health through increased tobacco use and alcohol consumption; poor housing conditions and inadequate diet; stress around debt and poverty, social withdrawal and family disruption;78

Poor work conditions (e.g., exposure to hazards and the physical impact of manual labour) can impact on physical health;79

How people perceive their own health is seen as a good indicator of overall well-being. There is an association between poor self-rated health and future disease, functional decline, use of healthcare services and mortality;80

For older people, good living conditions are important to maintaining good physical and mental health.81 Living conditions may be seen in terms of the building itself (problems with damp and mould, the structure of the building or with pests) and how comfortable the building is to live in (heating). The older housing stock is more likely to exhibit problems related to damp and moisture ingress and these houses are more likely to be occupied by older people;82

Cold weather and cold houses can have serious implications for people’s health.83 Adults who have difficulty heating their homes are more likely to have poorer self-rated health, clinically relevant depressive symptoms and chronic pain.84 Cold living conditions are associated with increased mortality due to exacerbation of respiratory and cardiovascular conditions and increased incidence of stroke as well as increased morbidity in terms of arthritis, colds and flus and increased risk of accidents and injuries;85 and

The health consequences of poor housing conditions is not confined to the older cohorts of the population. For children living in cold homes there may be longer term health outcomes such as cardiovascular and respiratory illnesses. When children live in overcrowded households there is an increased risk of childhood / adolescent depression, slower physical growth and slower cognitive development and limited educational attainment.86

78 Waldron and Lye, 1989; Popovici and French, 2013; Brand, 2014; Drewnowski and Specter, 2004; Gallo et al., 1999; Marmot Review Team, 2011. 79 Marmot Review Team, 2010. 80 Donoghue, O’Connell and Kenny, 2016; Idler and Benyamini, 1997; DeSalvo, Bloser, Reynolds et al., 2006; Lee, 2000. 81 Breen, 2013. 82 Orr, Scarlett, Donoghue and McGarrigle, 2016. 83 The World Health Organisation recommends that indoor home temperatures are kept at a minimum of 18°C and even higher for sedentary older adults. (World Health Organization, 1984.) 84 Pisters, Veenhof, van Dijk et al., 2012; Mezuk, Edwards, Lohman et al., 2012. 85 Gibney, S., M. Ward and S. Shannon, 2018. Fuel poverty refers to households that have difficulties heating their homes. A household having to spending 10% or more of household income on heating is seen as a key threshold in terms of identifying fuel poverty and it has been estimated that a quarter of all Irish households spent more than 10% of household income on heating. It has also been reported that half of older people in Ireland went without food or new clothing in order to pay for heating bills and are likely to forego heating and food if they have other high priority bills such as mortgages to pay. (Collins, 1986; Department of Communications, Energy and Natural Resources, 2015; Goodman, 2011.) 86 Allen and Daly, 2016; Marmot Review Team, 2011.

https://www.emerald.com/insight/search?q=Sarah%20Gibneyhttps://www.emerald.com/insight/search?q=Mark%20Wardhttps://www.emerald.com/insight/search?q=Sinead%20Shannon

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Lived Old Age in Ireland – Health and Well-Being The purpose of this section is to set out the empirical evidence of how old age is lived in Ireland. The structure of this section is based around the factors set out in Table 1 as these are central to understanding health and well-being in older age. The data is presented in a way that not only focuses on the individual factor but sets out how the various factors are related to each other. In terms of designing policy and interventions it is important to be cognisant of these relationships. That said, it should also be recognised that the relationships presented here are not causal relationships. This section of the paper draws on the substantial research that has been undertaken over the last decade or so on older people in Ireland. One key contribution to this effort has been The Irish Longitudinal Study on Ageing (TILDA). This is a nationally representative survey of the older population in Ireland that provides a comprehensive picture of the characteristics and contributions of older persons in Ireland. A second important contribution in this area has been the annual Healthy Ireland Survey. This survey collects data on the adult population as a whole in order to support the monitoring and assessment of the various policy initiatives Healthy Ireland Framework. The Healthy and Positive Ageing Initiative (HaPAI) Survey completed 10,540 interviews of community-dwelling members of the population aged 55 years and older who were living in private households in 20 local authority areas. The survey was carried out to provide evidence about the experiences and preferences of older people and to identify the gaps in services and supports needed to allow them to age positively in their local communities.87 While the data presented here focus for the most part on older adults, it is important to remember that both the National Positive Ageing Strategy and Healthy Ireland promote a life course approach to health and well-being in older age. As noted above, in older age, a person’s health and well-being is not just associated with their current circumstances and behaviours but is the accumulation of positive and negative effects of social, economic and environmental conditions throughout their life (i.e. the circumstances in which people are born, grow up, live, work and age).

Quality of life Quality of life is an important measure of well-being. It is a multi-dimensional concept encompassing not only a person’s physical health but also their psychological wellbeing, social functioning and participation in the world around them. Quality of life focuses on a person’s ability to actively participate in the place where they live, live their life in a way that allows them to fulfil their potential and derive happiness or enjoyment and be free from the unwanted interference of others.88 In TILDA, quality of life is seen in terms of needs satisfaction and is measured along four domains of “control” and “autonomy” (prerequisites for an individual’s free participation in society) and “self-realisation” and “pleasure” (active and self-reflexive aspects of living that bring reward and happiness to people in later life).89

87 Gibney et al., 2018. 88 McGarrigle and Ward, 2018; McGee, Morgan, Hickey, Burke and Savva, 2011; Bowling and Dieppe, 2005. 89 McGee, Morgan, Hickey, Burke and Savva, 2011.

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McGee et al. (2011) have found that overall, older people in Ireland feel that they experience high levels of quality of life:

Control refers to a person’s ability to actively participate in their environment. To a large degree, older Irish people feel they are free to plan for their futures and rarely feel that what happens to them is out of their control, that they are left out of things or that their age prevents them from doing things they like to do;

Autonomy refers to the right of the individual to be free from the unwanted interference of others. To a large degree, older Irish people feel that they can do the things that they want to do and they rarely feel that family responsibilities or their health prevents them from doing what they want to do;

Self-realisation refers to the fulfilment of one’s potential. To a large degree, older Irish people feel full of energy and feel optimistic about the future and positive about the past; and

Pleasure refers to the sense of happiness or enjoyment derived from engaging with life. To a large degree, older Irish people feel that life has meaning, look forward to each day, enjoy the things that they do and the company of others and look back on their life with a sense of happiness.

Research utilising the TILDA data has shown that quality of life is associated with90:

Age – The evidence suggests that quality of life does not decrease linearly with age but instead increases to a peak at 68 years and then starts to gradually decline;

Marital status - Those who were married have a higher quality of life than those who were separated or divorced;

Education - Those who had tertiary education have a higher quality of life than those who at best had primary level education;

Self-rate health status - Those who rated their health as either excellent or good have higher quality of life than those who rated their health as either fair or poor;

Wealth - Those in the most well-off quartile have a higher quality of life than those in the least well-off quartile;

Social integration – There was a positive association between social integration and quality of life with social isolation being associated with lower quality of life. The quality of these relationships is also important in that people who reported having positive supportive relationships with friends were also more likely to report a higher quality of life relative to those with less supportive relationships. As such then, quality of life in older life is not just about having active social interactions it is also about having quality relationships (i.e. both quantity and quality are important);

Chronic conditions – There was a negative association between the number of chronic conditions and quality of life; and

90 McGarrigle and Ward, 2018; McGee, Morgan, Hickey, Burke and Savva, 2011; Ward, McGarrigle and Kenny, 2018.

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Disability - For both ADLs and IADLs, quality of life decreased with increasing numbers of limitations.

Health Status

Physical Health There are increases in both the prevalence and incidence of poor health as people and populations age. McNicholas and Laird (2018) have found an overall increase in the prevalence of chronic health conditions across the first four waves of TILDA:

Hypertension (35% to 38%),

Diabetes (8% to 11%),

Heart attacks (4% to 6%),

Strokes (1% to 2%) and

Transient ischaemic attack (TIA) (2% to 4%). In particular, the increases in diabetes and heart attacks were most evident in men while the older age group (75 years and older) reported a higher prevalence of cardiovascular conditions than the younger age group (50-64 years). McNicholas and Laird (2018) have also found increased prevalence of:

Cataracts (9% to 14%),

Osteoporosis (9% to 17%),

Arthritis (26% to 39%) and

Lung disease (4% to 5%). The highest burden of both osteoporosis and arthritis was among older women (75 years and older) increasing their risk of disability and reduced physical activity. Cataracts were common in the older age group but it is worth noting that their prevalence increased amongst women aged 50-64 years between Waves 1 and 4 of TILDA.

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Disability There are many types of disability. A distinction is often drawn between those that impact on “activities of daily living” (e.g. washing, eating and toileting which are essential to daily life) and “instrumental activities of daily living” (e.g. preparing meals, managing money and household chores which are important in maintaining independence). McGarrigle and Ward (2018) have examined disability amongst Irish people aged 50 years and older and have found that:

8% of men and 11% of women reported at least one activity of daily living impairment;

6% of men and 7% of women reported at least one instrumental activity of daily living impairment; and

The highest number of limitations were evident in men and women aged 75 and over. The HaPAI Survey (2018: 62) has found that while more than half of those aged 55 years and older do not have a long-standing illness or condition that limits daily activity, almost 7% have such a condition that severely limits their daily activity while 22% have reported that their daily activity is limited (14% have reported that they have such a condition but their daily activity is not limited).

Frailty Frailty is a distinctive health state that is a recognisable and common phenomenon in ageing.91 TILDA utilised the Cumulative Deficit, or Frailty Index, that views frailty as a state of system breakdown due to the accumulation of physical, social and psychological health symptoms and conditions. It measures the number of health deficits present as a proportion of the total number of potential health deficits tested to determine whether a person is in “robust health”, “living with pre-frailty” or “living with frailty”.92 O’Halloran and O’Shea (2018) have examined the issue of frailty in the Irish population aged 50 years and older. They have found that between Waves 1 and 4 of TILDA:

The prevalence of robustness decreased from 56.4% to 41.8%.

The prevalence of pre-frailty increased from 30.9% to 39.2%; and

The prevalence of frailty increased from 12.7% to 19.0%;

91 The gold standard for the assessment and management of frailty is the Comprehensive Geriatric Assessment (CGA). This is a holistic and interdisciplinary assessment of an individual and has been demonstrated to reduce adverse outcomes including disability, cognitive decline, long-term residential care and death. However, CGA is time consuming and must be carried out by trained clinicians so it is not feasible for everyone living with frailty to undergo a full multidisciplinary review. (See: Ellis, Whitehead, Robinson et al., 2011) 92 An alternative screening method is the Frailty Phenotype model that views frailty as the presence of three or more of the following characteristics: unintended weight loss, exhaustion, weakness, slow gait speed and low physical activity. A person is considered pre-frail if they have 1-2 characteristics and robust if they have none of these characteristics. (See: Rockwood and Mitnitski, 2007; Searle, Mitnitski, Gahbauer et al., 2008; Fried, Tangen, Walston et al., 2001; Fried, Ferrucci, Darer et al., 2004.)

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o The prevalence of frailty among women was higher at all waves and was

approximately twice that of men at Waves 2-4;

o Frailty was twice as prevalent among those who attained a primary level of education compared to those who attained secondary level and over three-times more prevalent compared to those who attained third level education;

o The prevalence of frailty was lowest in those who were married and highest in

those who were widowed;

o The prevalence of frailty among adults aged 50 years and older who lived alone was approximately twice that of older adults who lived with other people;

O’Halloran and O’Shea (2018) have suggested that the increasing prevalence of pre-frailty and frailty was mainly due to the ageing of the cohort between Waves 1 and 4. By focusing on the incidence of frailty (i.e. the rate of occurrence of new cases), O’Halloran and O’Shea (2018) have examined how the Irish population has transition between the various states of fraility. Of those who were:

Robust at Wave 1:

o The majority (64%) remained robust at Wave 4 but

o 31% were pre-frail at Wave 4 and

o 5% were frail at Wave 4;

Pre-Frail at Wave 1:

o The majority (58%) were pre-frail at Wave 4 and

o 18% were robust at Wave 4 but

o Almost a quarter were frail at Wave 4;

Frail at Wave 1:

o The majority (67%) were frail at Wave 4 but

o 31% were pre-frail at Wave 4 and

o 2% were robust at Wave 4. Compared to those who are robust or pre-frail, frail older people tend to be:

older;

have worse health;

have lower levels of education;

experience more falls;

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have more disabilities; and

use more medications and healthcare services.93 O’Halloran and O’Shea (2018) have examined the relationship between frailty and mental health as frailty may be a risk factor for, and a consequence of, decline in cognitive function, and found that:

Based on data derived from the mini–mental state examination (MMSE), individuals living with frailty had exhibited worse cognitive function than those living with pre-frailty or robust individuals. Furthermore, they found evidence of a progressive decline in global cognitive function among those living with pre-frailty and frailty; and

At each wave, the group with frailty reported higher levels of depressive symptoms than the pre-frail and robust groups.

Falls Frailty is a known risk factor for falls. Falls are the leading cause of injury, disability and admission to nursing homes for people aged 65 years and older. TILDA collected self-reported data on the number of falls. McNicholas and Laird (2018) have noted that, by Wave 4 of TILDA, 52% of participants had reported at least one fall. O’Halloran and O’Shea (2018) have examined:

Number of falls by the prevalence of frailty:

o The prevalence of single falls was highest among people living with frailty compared to those with pre-frailty or those who were robust;

o The prevalence of recurrent falls was highest among people living with frailty

compared to those with pre-frailty or those who were robust; and

o Those who were robust were much less likely to have recurrent falls compared to single falls.

Cognitive Function and Dementia As people age they may encounter difficulties with one or more elements of memory that impact on their ability to perform everyday tasks. Dementia is a progressive condition that impacts on memory, language, ability to communicate, mood and personality. The prevalence of dementia in Ireland has been estimated at just over 55,260 individuals with about 59% of these cases in people aged 75-89 years. As dementia is more prevalent amongst older age groups, its prevalence is expected to increase over the coming decades in line with demographic projections. It is estimated that

93 Roe, O’Halloran, Normand and Murphy, 2016; O’Halloran and O’Shea, 2018.

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the number of cases of people with dementia will increase to some 95,860 by 2031 and some 157,880 by 2046.94 TILDA included a number of cognitive tests that were administered to participants at each wave of data collection.95 Using the TILDA data, Feeney and Tobin (2018) have examined cognitive change over time in adults of 50 years and older. In setting out these results it is important to note that participants lived in their communities when recruited to TILDA and the interviews were carried out in person (i.e. the results represent individuals without severe cognitive impairment). Feeney and Tobin (2018) have found that:

Overall there was little change in cognitive function across the four waves of TILDA, particularly in adults who were aged less than 75 years at Wave 1. While they did observe a small decline in cognitive function in those aged 75 years and over this was likely to have a negligible effect on the everyday functioning and was in keeping with international evidence;

The overall level of cognitive performance was impacted by education whereby individuals who had more years of formal education consistently performed better on the tasks than those who had received less education;

Women performed better than men in the immediate and delayed recall tasks; and

In the oldest age group, men performed better than women on the test of verbal fluency.

It has been suggested that the degree to which a person is socially integrated rather than isolated can influence their psychological and physical health and may be important for maintaining good cognitive function in later life. However, when Feeney and Tobin (2018) examined change in objective cognitive performance according to how well socially integrated participants were at Wave 1 of TILDA, they found, in the main, that there were no significant differences in word recall performance, prospective memory or MMSE scores between social integration groups at any wave.

94 Pierce and Pierse, 2017: 28-29. In terms of putting the projections in context, it is worth noting that those aged 75 years in 2031 will have been born in 1956 while those aged 75 years in 2046 will have been born in 1971. 95 The cognitive measures are designed to test several different aspects of cognitive function: verbal memory (10-word list learning and recall), prospective memory (remembering to do something at a later point in time) and participants’ own perception of their memory functioning (self-rated memory). Executive function is an umbrella term given to a number of cognitive abilities that are required for goal-directed action, including planning, mental flexibility and the ability to suppress inappropriate or incorrect responses. In TILDA, executive function is assessed using a verbal fluency task. Global cognitive function is assessed using the Mini-Mental State Examination (MMSE), a brief 30-point test comprising several domains of cognitive function (e.g. orientation, memory, language, spatial ability, attention and abstract thinking).

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Behavioural Factors

Health Risk Behaviours Behavioural health refers to modifiable risk factors (e.g., smoking, alcohol consumption and diet) that can have a negative influence on health and contribute to chronic disease.96

Smoking

Smoking is a well-known risk factor for a variety of conditions, in particular, cardiovascular and lung diseases and also plays a role in other non-life-threatening chronic conditions such as cataracts and osteoporosis.97 The cumulative effects of smoking over the life course means that the disease burden falls disproportionately on older people.98 In TILDA, smoking status was assessed at each wave by identifying participants as non-smokers, past smokers or current smokers. Over the four waves of TILDA, there has been an overall decrease in the proportion of current smokers (from 19% to 13%). Those in the oldest age cohort (75 years and older) were less likely to be a current smoker than those aged 50-64 years.99 Similar findings are evident in the Healthy Ireland Survey (2018: 8-9). The prevalence of smoking in the population as a whole is 20% but it is less prevalent amongst those aged 65-74 years (13%) and 75 years or older (8%). The HaPAI Survey (2018: 62) has reported that 18% of those aged 55 years and older are current smokers with 29% of respondents reporting that they are former smokers.

Alcohol Consumption

The consumption of alcohol is responsible for a wide range of health and social harms in society. The World Health Organization has reported that the harmful use of alcohol is a causal factor for more than 200 diseases and injury conditions and can cause death and disability relatively early in life.100 In order to calculate the number of units of alcohol consumed each week, participants in TILDA were asked if they drank alcohol, what drink did they typically consumed, how often and how much in an average sitting. Participants were also asked whether they had attempted to cut down their alcohol intake. McNicholas and Laird (2018) have found that:

Levels of alcohol consumption were higher in men than women at all age groups;

Levels of consumption decreased with age (over 40% of women aged 75 years and older reported that they did not drink any alcohol);

33% reported that they had attempted to cut down their alcohol intake in the last 2 years;

14% of participants reported that they had never consumed alcohol; and

96 McNicholas and Laird, 2018. 97 Wald and Hackshaw, 1996. 98 Hudson, Madden and Mosca, 2015. 99 Only 12 people who were non-smokers at Wave 1 commenced smoking during the subsequent three waves. 100 World Health Organization, 2014.

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Problematic alcohol use was more prevalent in men than women and decreased with age in both sexes.

The Healthy Ireland Survey (2018: 12-13) has shown that as people age they are less likely to drink alcohol. The prevalence of alcohol consumption decreases from 75% amongst those aged 55-64 years to 53% amongst those aged 75 years and older. While excessive consumption of alcohol101 also decreases with age, it is evident that this behaviour is notably greater amongst males than females. For instance, 52% of males aged 55-64 years binge drink as compared with 9% of females and 25% of males aged 75 years and older binge drink as compared with1% of females. The HaPAI Survey (2018: 62) has reported that almost a quarter of people aged 55 years and older have consumed alcohol weekly (including daily) in the past 6 months with just over a quarter doing so once or twice a month.

Diet

Obesity is a major health concern (i.e., excess body fat to the extent that health may be impaired). It is associated with reduced life expectancy at 50 years of age and with increased risk of disability, depression, type-2 diabetes, frailty and cardiovascular disease.102 Obesity is caused by an energy imbalance (consuming more calories than are used up in activity combined with increasingly sedentary lifestyles). The factors contributing to obesity are modifiable as energy intake does not increase with ageing but the level of physical activity is likely to decrease.103 In recent decades, the prevalence of obesity has increased dramatically in many countries, including Ireland.104 The Healthy Ireland Survey (2018: 14-15) has reported that the daily consumption of unhealthy foods105 amongst people aged 75 years and older (38%) is slightly greater than it is amongst the population as a whole (34%); 34% of those aged 65-74 years do so as do 32% of those aged 55-64 years. Furthermore, the daily consumption of fruit and vegetables decreases with age from 40% amongst 55-64 year olds to 25% amongst those aged 75 years and older. Using the Body Mass Index, an indicator of overall body fatness, Leahy et al (2014a, 2014b) have found that obesity is more prevalent among men (38%) than women (33%). The Body Mass Index data reported by the Healthy Ireland Survey (2017b: 27-28) have indicated that about 1-in-3 adults aged 55 years and older are obese with a further 4-in-10 being overweight. Leahy et al (2014a, 2014b) also considered an alternative metric, central obesity as measured by waist circumference. In older adults waist circumference is considered to be a more useful measure of obesity as fat deposited in this region is associated with greater risk of cardiac and metabolic disease.106 This data has shown that:

101 Drinking six or more standard units on a typical drinking occasion. 102 Preston and Stokes, 2011; Reuser, Bonneux and Willekens, 2009; Blaum, Xue, Michelon et al., 2005; Arterburn, Westbrook, Ludman et al., 2012; Katsiki, Ntaios and Vemmos, 2011; Magnani, Hylek and Apovian, 2013; Mokdad, Ford, Bowman et al., 2001; Marinou, Tousoulis, Antonopoulos et al., 2010; Wajchenberg, 2000. 103 Villareal, Apovian, Kushner and Klien, 2005. 104 World Health OrganiZation, 2000; Organisation for Economic Co-operation and Development, 2012; Irish Universities Nutrition Alliance, 2011. 105 Includes the consumption of sweets, cakes and biscuits, salted snacks, pastries and take-aways. 106 Lee, Huxley, Wildman and Woodward, 2008. Metabolic diseases are a cluster of conditions that occur together (e.g. increased blood pressure, high blood sugar, excess body fat around the waist,

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53% of Irish adults aged 50 years and older were “centrally obese” and at substantially increased risk of metabolic complications;

Women (56%) were more likely to have a substantially increased waist circumference than men (48%); and

Age differences were apparent as both men and women aged 65 years and older have significantly larger waist circumstances compared to those aged 52-64 years.

The Healthy Ireland Survey (2017b: 27) has noted that based on waist measurements, 19% of women aged 75 years and older have an increased level of risk of premature death due to obesity while 67% have a substantially increased level of risk. Obesity is an independent risk factor for cardiovascular disease. Leahy et al (2014a and 2014b) have shown that those with substantially increased waist circumferences were more likely than those with normal waist circumferences to have been diagnosed with:

Diabetes;

Higher prevalence of heart attacks;

Higher prevalence of angina;

High blood pressure or hypertension; and

High cholesterol. Within the Irish population the frequency of physically disabilities is low but Leahy et al (2014b) have found that substantially increased waist circumference is associated with a higher incidence of limitations with activities of daily living in both men and women (need help with walking across a room, dressing, bathing, eating, getting in and out of bed, and using the toilet) and a higher incidence of limitations with instrumental activities of daily living in women (preparing meals, shopping for groceries, making telephone calls, taking medications and managing money). Finally, the Healthy Ireland Survey (2016: 32) has also published data on the proportion of age cohorts who engage in two or more unhealthy behaviours. The data suggests that males are more likely to do so than females and that the likelihood of engaging in multiple unhealthy behaviours decreases with age. Amongst those aged 55-64 years, 53% of males and 25% of females engage in two or more unhealthy behaviours. In the cohort aged 75 years and older, 32% of males and 17% of females engaged in two or more unhealthy behaviours.

Physical Activity Physical activity is an essential component of a healthy lifestyle at all ages because it can help prevent disease, improve quality of life and promote physical and mental health.107 For older adults, walking is a common and accessible activity. In the HaPAI Survey (2018: 61) about

and abnormal cholesterol or triglyceride levels, that increase the risk of heart disease, stroke and type 2 diabetes). 107 McNicholas and Laird, 2018.

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two thirds of men and women have reported that they walk in their local area for health or fitness (70% amongst those aged 55-69 years and 59% amongst those aged 70 years and older). The National Guidelines on Physical Activity in Ireland recommend that all adults take part in at least 150 minutes of moderate activity each week.108 Participants in TILDA were asked to indicate the number of days and typical time each day spent walking and doing physical activities of vigorous or moderate intensity during the last week. Donoghue et al. (2016: 14) and McNicholas and Laird (2018: 102) have reported that large proportions of TILDA participants did not walk at least 150 minutes a week (40% to 48%). The lowest levels of walking was evident amongst adults aged 75 years and older, especially amongst women in this age cohort. The findings of the Healthy Ireland Survey (2016: 24-25) have suggested that Irish people feel that they do enough physical activity but across all of the age cohorts they fall notably short of the recommended guidelines. For instance, 60% of males and 50% of females aged 55-64 years feel that their activity levels are sufficient but only 33% of males and 18% of females achieve the recommended activity guidelines. The contrast is even greater amongst those aged 75 years and older where 54% of both males and females feel their levels of activity are sufficient but only 14% of males and 7% of females achieve the guideline levels. Gibney et al. (2018: 61) have used self-reported levels of physical activity in the HaPAI Survey to calculate the proportion of respondents complying with the National Physical Activity Guidelines recommendation. They have found that 51% of people aged 55 years and older engage in at least 150 minutes of moderate physical activity a week and that males and those aged 55-69 years are more likely to do so than females and those aged 70 years and older. In addition to having a better quality of life, Donoghue et al (2016) have found that Irish adults who participate in moderate or high levels of physical activity (e.g. walk for 150 minutes a week) were more likely than their counterparts to report:

Good, very good or excellent health;

Engagement in active social participation and formal organisational activities outside of work; and

Volunteering; and were less likely to report:

Feelings of loneliness (females only); and

Clinically relevant depressive symptoms.

Social Integration

People who engage in their communities are more likely to have better physical and mental health and are less at risk of pre-mature mortality. Social engagement is protective against cognitive decline and dementia and can influence levels of physical activity, healthy eating, and other positive health behaviours.109 However, low levels of social engagement are held

108 Department of Health and Children, 2009 109 Allen and Daly, 2016.

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to have a similar impact on people’s health as established risk factors such as physical inactivity, obesity, smoking and high blood pressure.110 The Healthy Ireland Survey (2015b: 44-45) has found that 52% of males and 43% of females participate in some form of social group or club. When age is taken into account, similar levels of participation are evident amongst those aged 55-64 years but there is a decrease in participation amongst males aged 65 years and older (45%). The HaPAI Survey (2018: 40 and 42) has found that 48% of people aged 55 years and older participate in community activities at least once a month (50% of males and 46% of females). Participation in community activities is slightly less amongst those aged 70 years and older (46%) than it is amongst those aged 55-69 years (49%). In terms of barriers to participation, 37% of people aged 55-69 years, and 41% of those aged 70 years and older, have reported that they experienced one or more barriers. With regard to the types of barriers encountered, about a tenth of respondents have reported that they either cannot get to the venue or the costs were too high. For just less than a tenth of respondents, a barrier to participation was people having negative attitudes towards older people being involved. The HaPAI Survey (2018: 129) has also found that 11% of people aged 55 years and older had experienced negative attitudes or behaviours towards them as an older person. In order to measure social participation, TILDA participants were asked to indicate how often they took part in a range of activities:

Intimate social relationships (e.g., daily visits to or from family and friends) - women were more likely to engage in this type of activity than men;

Formal organisational involvements outside of work (e.g., going to religious services or meetings at voluntary associations at least once a month) - men and adults aged 50-64 years were more likely to engage in this type of activity than women and adults aged 75 years and older; and

Active and relatively social leisure activities (e.g., going to classes, lectures, movies, plays and concerts, playing cards or bingo, eating outside the house, taking part in sports at least once a month) - men and adults aged 50-64 years were more likely to engage in this type of activity than women and adults aged 75 years and older.111

McGarrigle and Ward (2018) have noted that over a fifth of TILDA respondents reported the highest level of social integration with 39% reporting that they were moderately integrated. However, 29% of TILDA respondents felt that they were moderately isolated while 11% were recorded as most isolated. In addition to social integration, TILDA also sought to examine the quality of social support received from friends by asking respondents a series of questions about the relationship.112 McGarrigle and Ward (2018) have found that women were more likely to report positive supportive friendships than men. Both social integration and the quality of these relationships have been shown to have positive implications for people’s health and wellbeing.113 It is

110 Holt-Lunstad, 2017; Donoghue, O’Connell and Kenny, 2016; House, Robbins and Metzner, 1982. 111 Donoghue, O’Connell and Kenny, 2016. 112 These questions were: ‘Do you feel you can rely on them if you have a serious problem’, ‘how much do they understand the way you feel about things’, and ‘how much can you open up to them if you need to talk about your worries’. 113 Seeman, 1996; Nieminen, Harkanen, Martelin et al., 2015; Holt-Lunstad, Smith and Layton, 2010; Wahrendorf and Siegrist, 2010; Windsor and Anstey, 2010; McMunn, Nazroo, Wahrendorf et al., 2009; Santini, Koyanagi, Tyrovolas and Haro, 2015.

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posited that this benefit is a consequence of positive emotions and buffering the harmful effects of stress.114 The HaPAI Survey (2018: 128 and 131) has found that 15% of people aged 55 years and older and 18% of those aged 70 years and older feel isolated some or all of the time (around 3% of each cohort feel isolated all of the time). Those who were most likely to feel socially isolated were those who were either single (never married), separated / divorced or widowed; living alone; fair or poor health; limited by illness; mental health difficulties; or materially deprived. Volunteering is on important source of social engagement and people who do so tend to have slower declines in self-rated health and physical functioning, slower increases in depression levels and lower mortality rates.115 In TILDA, just over a quarter of participants reported that they volunteer at least once a month (26%) with 15% reporting that they volunteer at least once a week. While the prevalence of volunteering amongst men and women is relatively similar, adults aged 65-75 years are more likely to volunteer than those aged 75 and older.116 Along similar lines, the HaPAI Survey (2018: 33) found that 25% of adults volunteered at least once a month in the past 12 months (15% reported that they volunteered at least once a week) with those aged 55-69 years more likely to do so than those aged 70 years and older.

Latent Factors

Adversity People of all ages encounter adversity. In general terms, adversity can be defined as a lack of positive circumstances or opportunities, which may be brought about partially by physical, mental or social losses, or by experiencing deprivation or distress.117 However, a person’s resilience can enable a person to deal with adversity so that it is not always something that is detrimental to their health or well-being.118 Resilience is both nature and nurture119 and ranges from “basic survival” to “flourishing resilience”.120

Adult Safeguarding (Elder Abuse)

The mistreatment and abuse of older people is an issue that has become more salient in public discourse over the last few decades. Older people who have experienced abuse are at risk of premature mortality, emotional distress, isolation from family and friends, the loss of self-confidence and self-esteem, depression and thoughts of suicide or self-harm.121 Naughton et al. (2010) examined the abuse and neglect of older people in Ireland focusing on five forms of elder abuse perpetrated by those in a ‘position of trust’ (e.g. a family member,

114 Berkman, Glass, Brissette and Seeman, 2000. 115 Donoghue, O’Connell and Kenny, 2016; Lum and Lightfoot, 2005. 116 Donoghue, O’Connell and Kenny, 2016. 117 Hildon, Smith, Netuveli and Blane, 2008. 118 Lyons, Mickelson, Sullivan and Coyne, 1998. 119 Masten, 2001; Harrop, Addis, Elliott and Williams, 2006. 120 Palmer, 1997. 121 Lachs, Williams O’Brien et al., 1998; Comijs, Pot, Bouter and Jonker, 1998; O’Keeffe, Hills, Doyle et al., 2007; Mowlam, Tennant, Dixon and McCreadie, 2007; Mears, 2003.

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close friend or care worker) in the previous 12 months.122 The study found that the overall prevalence of mistreatment in the previous 12 months was 2.2% (an estimated 10,200 people in terms of the general population of people aged 65 years or older). The most frequent type of abuse reported was financial abuse (1.3%), that is, being forced to give money or property to someone in a position of trust. The next most frequent type of abuse was psychological abuse (1.2%) which tended to involve verbal insults as well as actions to exclude or undermine the older person as well as verbal threats. The prevalence of physical abuse was 0.5% and in the most part related to being pushed, threatened or hit with an object, kicked, denied access to equipment (e.g., a walking or hearing aid) or being restrained. The prevalence of neglect was 0.3%.123 Of those respondents who had been abused in the last 12 months, about a quarter had experienced more than one type of abuse with 14% experiencing three or more types of mistreatment. In particular, Naughton et al. (2010) have noted that psychological abuse was likely to accompany other forms of abuse such as physical abuse, financial abuse and neglect. Naughton et al. (2010) have found that over the previous 12 months:

Women were more likely than men to have experienced mistreatment;